2025 CPT code 99396
(Active) Effective Date: N/A Revision Date: N/A Preventive Medicine - Preventive Medicine Services Evaluation and Management Feed
Preventive medicine reevaluation and management service for an established patient aged 40-64, including history, exam, counseling, and ordering of lab/diagnostic procedures.
Modifier 25 is appropriate if a significant, separately identifiable E/M service is performed on the same day as the preventive medicine service.Other modifiers may apply depending on the circumstances.
Medical necessity is established by the patient's age (40-64) and the need for age-appropriate preventive services to identify potential health problems and implement preventative measures.Payers may have specific requirements for preventive care coverage.
The physician's responsibility includes performing a comprehensive history and physical examination tailored to the patient's age and gender, providing counseling and anticipatory guidance regarding health risks, ordering appropriate laboratory and diagnostic tests, and discussing preventive measures.The physician may also administer immunizations (billed separately).
In simple words: This code covers a yearly checkup for established patients between 40 and 64 years old.The doctor reviews your health history, performs a physical exam, talks to you about preventing health problems, and may order blood tests or other checks.
This CPT code, 99396, represents a comprehensive preventive medicine reevaluation and management service for established patients aged 40-64 years.The service includes a detailed age- and gender-appropriate history, a comprehensive physical examination, counseling and anticipatory guidance addressing age-related risk factors, and the ordering of necessary laboratory or diagnostic procedures.Immunizations, if administered, are reported separately.If a significant, separately identifiable problem is addressed requiring additional work beyond the preventive medicine service, an additional E/M code (99202-99215) with modifier 25 may be reported.
Example 1: A 45-year-old established patient presents for their annual physical. The physician reviews their medical history, performs a complete physical exam, orders a lipid panel and basic metabolic panel, and discusses preventative measures such as diet, exercise, and screening tests for colorectal cancer., A 52-year-old established female patient comes in for her annual checkup.The physician discusses family history, performs a breast exam and pap smear (billed separately), addresses menopause-related concerns, and orders a bone density test., A 60-year-old established male patient presents for preventive care. During the visit, the physician detects an irregular heart rhythm.This finding prompts additional testing and evaluation which are documented using an additional E/M code with modifier 25.
Detailed documentation is crucial, including:
** This code should only be used for established patients.New patient preventive visits are coded differently.Always refer to the most current CPT codebook and payer guidelines for accurate coding and reimbursement.
- Revenue Code: M1B (Office Visits - Established)
- RVU: The RVUs for this code vary based on location, payer, and other factors. Consult the appropriate fee schedule for current values.
- Global Days : Not applicable. This is a preventive medicine service, not a surgical procedure with a global period.
- Payment Status: Active
- Modifier TC rule: Not applicable. This is not a procedure with technical and professional components.
- Fee Schedule : Fee schedules vary by payer and location.Refer to the appropriate fee schedule for historical and current payment rates.
- Specialties:Family Medicine, Internal Medicine, Geriatric Medicine
- Place of Service:Office